HCC: SYSTEMIC THERAPY FIRST LINE Akshjot Puri, MD Post Graduate - PowerPoint PPT Presentation

HCC: SYSTEMIC THERAPY FIRST LINE Akshjot Puri, MD Post Graduate Year 5 MENTOR: Madappa N. Kundranda, MD. PhD.

CASE A 72 yo female with history of HCV cirrhosis (Child Pugh A) is found to have liver masses on screening ultrasound AFP 1072 BCLC Stage B. Not a transplant or resection candidate

QUESTION 1 What would be a first line treatment choice for this patient? A.Y90 arterial embolization B.TACE C. Lenvatinib D. Liver directed therapy + Lenvatinib E. Sorafenib

At 5 months from diagnosis Y90 to right and left hepatic arteries with favorable treatment response AFP 1072  27 27

At 9 months from diagnosis AFP 1072  27  82 Star arted on Lenvat atinib-> unable to tolerate due to nausea, headaches and hot flashes Star arted on Sorafenib-> unable to tolerate due to chest pain few hours after medication, severe hand foot syndrome being unable to walk and extreme sensitivity to hot water, nose bleeds

QUESTION 2 What is the next choice of systemic therapy for this patient? A. Cabozantinib B. Ramucirumab C. Regorafenib D. Nivolumab E. Pembrolizumab

CASE • Patient was started on Nivolumab • After the 2 nd infusion patient developed a diffuse rash involving the face and upper trunk

QUESTION 3 What is the next step in therapy for this patient? A. Discontinue Nivolumab B. Start oral steroids C. Switch to Regorafenib D. Initiate topical steroids and continue to hold nivolumab

CASE • Patient was started topical steroids • Nivolumab was reinitiated after resolution of the rash • Restaging scans after 3 months demonstrated a partial response